Provider Demographics
NPI:1083123574
Name:YAZDI, NICOLE CERUTTI (MA, R-DMT, LCAT-LP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CERUTTI
Last Name:YAZDI
Suffix:
Gender:F
Credentials:MA, R-DMT, LCAT-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 MAXWELL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4185
Mailing Address - Country:US
Mailing Address - Phone:800-261-0127
Mailing Address - Fax:
Practice Address - Street 1:1150 MAXWELL AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4185
Practice Address - Country:US
Practice Address - Phone:800-261-0127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
R-DMT-2266225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health